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Treatment of Drug-Resistant Tuberculosis Fact Sheet										Related Pages
										**Treatment of Drug-Resistant Tuberculosis**
**Introduction**
Drug-resistant tuberculosis (TB) is TB disease caused by *M. tuberculosis* organisms that are resistant to at least one first-line anti-TB drug. Multidrug-resistant TB (MDR TB) is resistant to more than one anti-TB drug and at least isoniazid (INH) and rifampin (RIF). Treating and curing drug-resistant TB is complicated. Inappropriate management can have life-threatening results. Drug-resistant TB should be managed by or in close consultation with an expert in the disease.
Drug resistance is proven by drug-susceptibility testing. However, since this testing can take weeks, treatment should be started with an empirical treatment regimen based on expert advice as soon as drug-resistant TB disease is suspected. When the testing results are known, the treatment regimen should be adjusted according to the results. Patients should be monitored closely throughout treatment. Directly observed therapy (DOT) always should be used in the treatment of drug-resistant TB to ensure adherence.
**Special Considerations**
**HIV-Infected Persons**
Although the treatment of drug-resistant TB in persons with HIV infection is the same as for patients without HIV (see Table 1), management of HIV-related TB requires expertise in the management of both HIV and TB. Providers must monitor the interactions among many of the antiretroviral drugs. RIF should not be used with most antiretroviral drugs. Rifabutin, which has fewer problematic drug interactions, may be used in place of RIF. As new antiretroviral agents and pharmacokinetic data become available, these recommendations are likely to be modified. Visit Managing Drug Interactions in the Treatment of HIV-Related Tuberculosis for the most recent recommendations.
**Children**
Treatment for children who have TB disease after exposure to a drug-resistant case should be guided by the source-case susceptibility results. When a source is unknown and circumstances suggest an increased risk of drug resistance, children should be treated with a standard four-drug initial-phase regimen until their susceptibility pattern is known. Ethambutol (EMB) can be used safely (15-20 mg/kg per day), in the likelihood of INH resistance. Streptomycin, kanamycin, or amikacin also can be selected as the fourth drug. Long-term use of fluoroquinolones in children has not been approved. However, most experts agree that these drugs should be considered for children with MDR TB. Consultation with a specialist in pediatric TB treatment is recommended.
**Pregnant Women**
Case management for pregnant women who have drug-resistant TB requires consultation with an expert because most second-line drugs can have harmful effects on the fetus. Pyrazinamide (PZA) should not be used as part of the treatment regimen for pregnant women. Counseling concerning risks to the fetus should be provided.
Close Contacts of Drug-Resistant TB Patients*Contacts of isoniazid-resistant* TB. For persons who have been exposed to INH-resistant, RIF-susceptible TB and are known or suspected to have latent TB infection (LTBI), a 4-month regimen of daily RIF is recommended. When RIF cannot be used, rifabutin may be substituted.
*Contacts of MDR TB*. For persons with known or suspected LTBI resistant to both INH and RIF, alternative regimens should be considered. Alternative regimens should include two drugs to which the TB strain is susceptible. A potential regimen should include a daily fluoroquinolone. Contacts who are not immunosuppressed may be treated for 6 months or observed without treatment. All persons with suspected MDR LTBI should be monitored for 2 years regardless of the treatment regimen.
**For More Information**
American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America. Treatment of tuberculosis. *MMWR 2003*; 52 (No. RR-11).
American Thoracic Society and Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent TB infection. *MMWR 2000*; 49 (No. RR-6).
American Thoracic Society and Centers for Disease Control and Prevention. Update: Adverse event data and revised American Thoracic Society/CDC recommendations against the use of rifampin and pyrazinamide for treatment of latent tuberculosis infection. *MMWR 2003*; 52 (No. 31)
Centers for Disease Control and Prevention. Updated guidelines for the use of rifamycins for the treatment of tuberculosis among HIV-infected patients taking protease inhibitors or nonnucleoside reverse transcriptase inhibitors. *MMWR 2004*; 53 (No. 2).
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						Page last reviewed:  May 4, 2016					Content source: 	Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention homeTuberculosisBasic TB Factsplus iconHow TB SpreadsLatent TB Infection and TB DiseaseSigns & SymptomsTB Risk FactorsExposure to TBTB PreventionVaccinesTB & HIV CoinfectionTB and DiabetesTB TermsPersonal StoriesTesting & Diagnosisplus iconWho Should be TestedTesting for TB InfectionTesting in BCG-Vaccinated PersonsTB Screening and Testing of Health Care PersonnelTesting During PregnancyDiagnosing latent TB infection and TB diseaseTreatmentplus iconDeciding When to Treat Latent TB InfectionTreatment Regimens for Latent TB Infection (LTBI)Treatment for TB DiseaseAdverse EventsTB Treatment of Persons Living with HIVTB Treatment and PregnancyTB Treatment for ChildrenFrequently Asked QuestionsDrug-Resistant TBResearchplus iconTB Epidemiologic Studies Consortiumplus iconResearch ProjectsPublicationsTB Trials Consortiumplus iconStudy DescriptionsBackgroundBehavioral & Social Science ResearchHealth Care Settingsplus iconTB Infection Control in Health Care SettingsResources for TB Screening and Testing of Health Care Personnelplus iconFrequently Asked QuestionsTB in Specific Populationsplus iconHealth DisparitiesAsian PersonsBlack or African American PersonsHispanic or Latino PersonsChildrenPregnancyCorrectional FacilitiesPeople Experiencing HomelessnessInternational TravelersLaboratory Informationplus iconDrug Susceptibility TestingFalse-Positive Investigation ToolkitInterim Laboratory Biosafety Guidance for XDR  tuberculosis strainsModel Performance Evaluation Program (MPEP)Rapid Molecular Testing to Detect Drug-Resistant TB in the USplus iconExecutive SummaryIntroductionBackground on Tests for Molecular Detection of DRGeneral Considerations and Principles for a Molecular DR Testing ServicePossible Scenarios and Scope of Testing for a Molecular DR Testing ServiceResearch NeedsGeneral Recommendations of the Expert PanelCommunication Plan for the ReportRecommendationsReferencesPanel Members and CDC ParticipantsAppendix 1Appendix 2Appendix 3The Uses of Nucleic Acid Amplification Tests for the Diagnosis of TBplus iconGeneral ConsiderationsGeneral Recommendations of the Expert PanelRecommendations to ACET, CDC, DTBEData & Statisticsplus iconTB Incidence in the United StatesReported TB in the US, 2022 Surveillance Reportplus iconNational DataReporting Area DataRisk FactorsDemographicsTB Treatment and Case OutcomesDrug-Resistant TBMolecular SurveillanceTuberculosis in the United States, 2022 (Slide Set)Archived Surveillance Reports and Slide Sets2021 State and City ReportArchived State and City ReportsProfessional Resources & Toolsplus iconTools for Healthcare ProvidersResources for TB Programsplus iconStrengthening Civil Surgeons’ Capacity to Improve LTBI Surveillance and Outcomes Among Status AdjustersNotice of Funding Opportunity (NOFO)Program EvaluationTB Centers of ExcellenceTB Elimination AllianceTB Genotypingplus iconConventional TB GenotypingWhole Genome SequencingTB GIMSAnalytic ToolsLatent Tuberculosis Infection ResourcesPublications & Productsplus iconPatient and Public MaterialsFact SheetsGuidelinesplus iconControl & EliminationDrug-Resistant TBInfection Control & PreventionLaboratory & GenotypingTB & HIVTB in Specific PopulationsTesting & DiagnosisTreatmentVaccines & ImmunizationsArchived TB GuidelinesGuides & Toolkitsplus iconAggregate ReportsCDC TB Surveillance TrainingCore CurriculumEffective TB Interviewing for Contact InvestigationEthnographic GuidesFalse-Positive Investigation ToolkitForging Partnerships to Eliminate TuberculosisGuide to Application of GenotypingLTBI: A Guide for Primary Health Care ProvidersMantoux Tuberculin Skin Testing ProductsReport of Verified Case of Tuberculosis (RVCT)Self-Study ModulesTB Contact Investigation Interviewing Skills CourseTB eDOT ToolkitUnderstanding the TB Cohort Review ProcessNewslettersplus iconTB Notes, No. 4, 2023TB Notes, No. 3, 2023TB Notes. No. 2, 2023TB Notes. No. 1, 2023TB Notes, No. 4, 2022TB Notes, No. 3, 2022TB Notes, No. 2, 2022TB Notes, No. 1, 2022TB Notes, No. 4, 2021TB Notes, No. 3, 2021TB Notes, No. 2, 2021TB Notes, No. 1, 2021Pamphlets, Brochures, Bookletsplus iconQuestions and AnswersPatient Education SeriesTuberculosis - Get the FactsTuberculosis - The Connection between TB and HIV12-Dose Regimen for Latent TB Infection-Patient Education BrochurePostersplus iconMantoux Tuberculin Skin Test Wall ChartWorld TB DayThink TBStop TBTake on TBReports & Articlesplus iconDTBE Authored Journal ArticlesTuberculosis Laboratory Aggregate ReportsSlide Setsplus iconIntroduction to TuberculosisEpidemiology of Tuberculosis Among Non-U.S.​–Born Persons in the United States, 1993–2016Self-Study Modules on Tuberculosis, 1-5 Slide SetsThe Tuberculosis (TB) in Correctional Settingsplus iconFacilitator GuideIntroduction to TB GenotypingEpidemiology of Tuberculosis in Correctional Facilities, United States, 1993-2017Prevention and Control of Tuberculosis in Correctional and Detention FacilitiesGuidelines for Preventing the Transmission of M. TB in Health care SettingsInvestigation of Contacts of Persons with Infectious TBEpidemiology of Pediatric Tuberculosis in the United StatesTargeted Tuberculosis Testing and Treatment of Latent Tuberculosis InfectionElectronic Tools & ResourcesWeb-Based Courses & Webinarsplus iconTB 101 for Health Care WorkersContent SyndicationInfographicsplus iconSocial Media GraphicsCustomizable Take on TB Infographic with InstructionsEventsWorld TB Dayplus iconU.S. TB ChampionsHistoryFeaturesplus iconTB Risk FactorsTreating Latent TB Infection with Short-Course RegimensWorld Tuberculosis (TB) Day 2021World Tuberculosis (TB) Day 2020Linksplus iconState TB Control OfficesAbout Usplus iconMission Statement and Activitiesplus iconDTBE Strategic PlanNational TB Program ObjectivesOrganization ChartAdvisory Groupsplus iconFederal TB Task Force To receive email updates about this page, enter your email address: Email Address			What's this?				Submit


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